European Journal of Obstetrics & Gynecology and Reproductive Biology 185 (2015) 3335

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Intra-abortion contraception with etonogestrel subdermal implant

Isabel Barros Pereira *, Rui M. Carvalho, Lus M. Graca
Clnica Universitaria de Obstetrcia e Ginecologia, CHLN, Hospital Universitario de Santa Maria, Faculdade de Medicina da Universidade de Lisboa,
CAM Centro Academico de Medicina de Lisboa, Lisbon, Portugal

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Etonogestrel subdermal implant is a highly effective, reversible and safe form of
Received 11 October 2014 contraception. Immediate placement during abortion visit could increase contraception use in women
Received in revised form 17 November 2014 at high risk for unintended pregnancy. Our purpose was to evaluate patient acceptability, user
Accepted 21 November 2014
continuation rate and efcacy of medical termination of pregnancy when the implant is inserted during
medical termination of pregnancy.
Keywords: Study design: Prospective observational study comparing patients who chose the subdermal implant for
Long-acting reversible contraception
post-abortion contraception, inserted at the time of administration of mifepristone, with patients who
Intra-abortion contraception
chose delayed placement after the termination was complete.
Etonogestrel subdermal implant
Results: After contraceptive counseling 119 women chose the implant as their post-abortion
contraceptive method. In the intra-abortion implant insertion group the user continuation rate after
6 months was 73.7% (42/57). In the delayed placement group 59.7% (37/62) missed the follow-up after
abortion visit, 24.2% (15/62) chose another method and only 16.1% (10/62) had the implant inserted. The
efcacy of medical termination was 96.5% in the group of intra-abortion implant insertion and 98.4% in
the delayed placement group.
Conclusions: Intra-abortion subdermal implant insertion signicantly increases the likelihood of
effective long-acting contraception use following abortion. The efcacy of medical termination was not
signicantly changed by intra-abortion implant insertion.
2014 Elsevier Ireland Ltd. All rights reserved.

Introduction It is crucial to start an effective contraceptive method at the

Throughout the world an estimated 46 million women lacking
adequate, effective contraception have an induced abortion each
year. Of these, 95% take place in the developing world [1]. Some
countries of western Europe have the lowest abortion rate in the
world, at 12 per 1000 women. By contrast, eastern European
countries have higher estimated abortion rates [2]. In 2008, in the
United Kingdom, of the women who had a pregnancy termination,
33% had one or more previous terminations [3].
Abortion is usually the result of contraceptive method failure,
inadequacies in the family planning service or inadequate
behavior. The importance of each of these factors varies between
countries, and even within a country differences exist among
different socio-economic groups. According to Cameron et al., 83%
of women undergoing an abortion were using a contraceptive
method at the time of conception [4].
* Corresponding author at: Rua Joaquim Rocha Cabral, n8 24, 48 D, 1600-086
Lisbon, Portugal. Tel.: +351 967035610.
E-mail address: isabelsoapereira@yahoo.com (I. Barros Pereira).
time of abortion because in about half of women ovulation occurs
within 23 weeks after a rst trimester pregnancy termination.
In addition, not all women return for post-abortal check-ups
[5]. Immediate post-abortion contraception is easily carried out in
the case of surgical abortion. It is a more complex endeavor in the
event of a medical abortion, a procedure that may last 36 h. Post-
abortal contraception provides a unique opportunity for couples to
be enrolled into family planning services since, after abortion, both
patient and health care personnel are highly motivated to start
contraceptive use.
Long-acting reversible contraceptive (LARC) methods are safe
and effective, associated with low failure rates, and more cost-
effective than the oral contraceptive pill [6]. Greater use of
long-acting methods by women who are at high risk for
contraceptive failure has the potential to signicantly reduce
unintended pregnancies and repeated terminations. Goodman
et al. showed that women receiving immediate post-abortal
intrauterine device (IUD) insertion have a signicantly lower
rate of repeated abortion [7].
A contraceptive implant impregnated with 68 mg of etonoges-
trel, the biologically active metabolite of desogestrel, offers 3 years

http://dx.doi.org/10.1016/j.ejogrb.2014.11.025
0301-2115/ 2014 Elsevier Ireland Ltd. All rights reserved.
34 I. Barros Pereira et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 185 (2015) 3335

of contraceptive efcacy, through controlled release of the Statistical analyses were performed using SPSS 20 (SPSS
hormone [8,9]. It has high efcacy, with a pregnancy rate of less Inc., Armonk, NY) and p < 0.05 was considered as statistically
than 1/1000 over 3 years [1]. The main side effect of the implant is signicant.
unpredictable vaginal bleeding. Whilst 20% of women will be
amenorrheic, 50% will have infrequent, frequent or prolonged
bleeding and this is the most common reason for discontinuation Results
[3]. A review of 11 international trials reported discontinuation
rates of about 13.1% in the United States, 13.6% in Europe and 5.1% After contraceptive counseling, 129 women chose the etono-
in Southeast Asia, due to bleeding irregularities or amenorrhea gestrel subdermal implant as their post-abortal contraceptive
[10]. Croxatto et al. describe an overall discontinuation rate at method. Participation in the study was proposed after women
6 months for any reason of 10% [11]. decided the timing of implant placement. Ten women refused to
Immediate post-abortion contraception remains unexplored, participate in the study (4 in the immediate placement group
with only a small number of studies focusing the use of and 6 in the delayed placement group). The nal sample was
contraceptive pills at the time of the termination and even 119 women. Information at 6 months was complete for all women.
fewer regarding the use of etonogestrel subdermal implants. The mean age was 25 years (ranging between 15 and 41 years).
Madden et al. concluded that women who undergo immediate A total of 89 women (74.8%) mentioned using a contraceptive
placement of a subdermal implant after a surgical abortion have method at the time of conception and 30 women (25.2%) did
high rates of continuation, which are equivalent to women not use any contraceptive method. Oral contraceptives were the
undergoing interval insertion [12]. Sonalkar et al., in a pilot study most used method (48/89: 53.9%) followed by the use of a condom
with 20 participants, showed that initiation of the contraceptive (31/89: 34.8%). Demographic and reproductive characteristics of
implant on the initial visit for medical abortion results in high women in both groups are presented in Table 1.
satisfaction and continuation rates [13]. Fifty-seven women (47.9%) opted to insert the implant when
Our study aimed to evaluate the acceptability and user mifepristone was administered. In this group the user continuation
continuation rate of etonogestrel subdermal implant inserted rate 6 months after insertion was 73.7% (42/57). Changes in the
during the abortion appointment, at the time of administration menstrual pattern were given by 5 women (33.3%) as the main
of mifepristone. We also sought to determine if intra-abortion reason for removal. Less frequent causes included acne (4/15:
insertion of the implant at this time interferes with the efcacy 26.7%), weight gain (4/15: 26.7%) and desire to become pregnant
of medical pregnancy termination. (2/15: 13.3%). In this group the medical interruption of pregnancy
was effective in 55 women (96.5%). In 2 women, due to incomplete
Materials and methods abortion, surgical intervention was necessary to complete the
termination.
We conducted a prospective observational study of women Sixty-two women (52.1%) preferred to have the implant placed
choosing the subdermal etonogestrel implant as their contracep- after the termination procedure and were sent a family planning
tive method during medical pregnancy interruption appointment appointment. When asked about the follow-up appointment
at our Department, in the period between January 2008 and 37 women (59.7%) said they had missed the post-abortion visit,
March 2013. During this appointment women were given 15 women (24.2%) opted for another contraceptive method and 10
information about contraceptive methods and, when choosing
the etonogestrel implant, asked for consent for participation in this
study. All methods were freely available. Table 1
Demographic and reproductive characteristics of women receiving an etonogestrel
The maximum gestational age for interruption was 10 weeks implant by the timing of placement.
(determined by ultrasonography) as this is the upper legal limit for
voluntary pregnancy interruption in Portugal. The department Immediate Delayed implant
implant insertion insertion
protocol for medical abortion was as follows: 200 mg of oral (N = 57) (N = 62)
mifepristone followed 48 h later by 800 mg of oral misoprostol.
n % n %
Clinical assessment for completion of abortion was made 14 days
later by vaginal ultrasound. Vacuum aspiration was performed Mean age, years 26.3 24.6
if a viable pregnancy or an incomplete abortion (dened as Race
Black 19 33.3 22 35.5
endometrial thickness of more than 15 mm) were detected. White 33 57.9 36 58.1
These women were divided into two groups: one included Other 5 8.8 4 6.4
women who chose the immediate placement of the implant during Body mass index
the appointment and the second group consisted of women who Lower than 25 34 59.6 40 64.5
2530 16 28.1 14 22.6
preferred delayed implant placement at a family planning
Higher than 30 7 12.3 8 12.9
appointment. The timing of insertion was independently chosen Use of contraceptive
by the woman. Women who preferred the delayed placement were method
asked to arrange a family planning appointment in four weeks. Yes 45 78.9 43 69.4
Both the family planning appointment and the implant insertion No 12 21.1 19 30.6
Marital status
were freely available. Single 39 68.4 35 56.5
All women in both groups were routinely contacted by personal Married or living 11 19.3 17 27.4
telephone interview, regarding user continuation rate 6 months with a partner
after insertion, need for aspiration to complete the medical Separated, divorced 7 12.3 10 16.1
or widowed
interruption and, in the case of removal, the main reason for
Nulliparous
discontinuation of the method. Women who opted for delayed Yes 24 42.1 29 46.8
placement were also asked about the appointment attendance and No 33 57.9 33 53.2
the effective insertion of the implant. Data verication to History of prior abortion
determine the pregnancy outcomes was done by examining all Yes 20 35.1 18 29
No 37 64.9 44 71
womens hospital records.
 I. Barros Pereira et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 185 (2015) 3335
(16.1%) actually had the implant inserted. Of the 37 women who
missed the follow-up appointment, 29 (78.4%) continued their
previous contraceptive method and 8 (21.6%) remained without
contraception. One woman had an incomplete abortion requiring
surgical intervention to complete the interruption, giving a
medical termination efcacy rate of 98.4% (61/62). There was
no statistically signicant difference between the groups in the
need for surgical intervention (98.4% complete vs 96.5%, p = 0.47).
Comment
Contraceptive counseling is an integral part of the abortion
visit. In the majority of cases LARC methods are not offered to
women as immediate post-abortion contraception. These highly
effective methods and their nancial feasibility have the potential
to decrease rates of repeated unintended pregnancies [7]. Cameron
et al. showed that either intrauterine contraception or progesto-
gen-only implant are associated with a substantial decrease in
repeated abortion rates [4].
In our sample, the majority of women (74.8%) were using a
contraceptive method at the time of conception. The majority of
unintended pregnancies occurred in women using barrier methods
or oral contraceptive pills. The efcacy of these contraceptive
methods depends on their correct and consistent use. In contrast,
long-acting reversible contraception has a high effectiveness that
does not depend on daily compliance. At the time of abortion
women are highly motivated to start an effective contraceptive
method and many are inclined to discontinue their previous
method, which has failed [3].
In our study, in women who had the implant inserted during the
abortion visit the discontinuation rate at 6 months (26.3%) was
slightly higher than those described in other studies, but the main
secondary effects leading to removal resembled those described in
the literature. Croxatto et al. found a discontinuation rate of the
subcutaneous implant at 6 months of 10%, and that the majority of
women discontinuing the method did so because of an unaccept-
able bleeding pattern [11]. Casey et al. describe a removal rate
due to hemorrhage of 14.8% [10]. In our study 33.3% of women
mentioned changes in the menstrual pattern as the main reason for
implant removal.
In the study by Croxatto et al., acne was one of the most
frequently reported adverse effects, being new or worsening in
12.6% of cases. These authors also found that in 2.4% of women
increase in body mass index was the reason given for removal
[11]. In our study acne and weight gain were mentioned by
the same percentage of women (26.7%) as the main reason for
implant removal.
The ability to initiate use of this method at the time of abortion,
without serious health risks and major side effects resulting from
its early insertion, is an important advantage of this contraceptive
method [5]. Furthermore, Martin et al. reported a higher tolerance
to the implant when it is inserted during the abortion [14].
Women undergoing an interruption of pregnancy are counseled
regarding contraceptive methods, but the majority of women
choosing the subdermal implant are usually referred to a family
planning visit to delayed insertion. If the clinician counseling
the patient regarding termination and contraception could t the
implant on the day of medical termination of pregnancy, rather
than referring to a separate contraceptive service, this would
provide a better service and ensure that patients have reliable
contraception with immediate effect. This is particularly important
because of the quick return of fertility after a rst-trimester
abortion.
There is concern that immediate subdermal implant insertion
could reduce the efcacy of medical termination due to elevated
35
serum progestogen levels, leading to the suggestion that higher
doses of mefepristone may be needed. According to Church et al.
the success of rst-trimester medical termination is not signi-
cantly decreased in women with immediate subdermal implant
placement. This study reported an efcacy of medical termination
of 89.7% in women with immediate implant insertion and of
97.4% in women starting other methods after the termination is
completed [3]. Further controlled studies would be necessary in
order to assess whether the presence of a progestogen contracep-
tive implant does affect the efcacy of rst-trimester medical
termination of pregnancy or whether this effect is confounded
by other variables.
Our results support the immediate insertion of the subdermal
implant as a valid option in women intending to avoid pregnancy.
The small risk of reducing the efcacy of medical termination
(96.5 vs 98.4%) has no statistical signicance and is balanced by
the high probability (59.7%) of women not returning to the follow-
up appointment and remaining without effective contraception.
The observational character of the study and the small numbers
in the sample are limitations of the study and could have biased
the results. The six-month follow-up is a short period, given that
the main reason for discontinuation is bleeding irregularity and
this may continue beyond six months. Furthermore, obtaining
data by telephone interview may have inuenced the accuracy of
the information collected, an issue which we tried to minimize by
consulting the clinical les.
Women undergoing pregnancy termination and wishing to
avoid further pregnancies should consider immediate subcutane-
ous implant placement, which is a reversible contraceptive option,
extremely effective and user independent. This intervention could
be widely applied in order to reduce repeated unintended
pregnancies.
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